Provider Demographics
NPI:1376825968
Name:MANTONG, KIMBERLY L (SLP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:MANTONG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 BEGLEY DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-7239
Mailing Address - Country:US
Mailing Address - Phone:951-738-1453
Mailing Address - Fax:
Practice Address - Street 1:41689 ENTERPRISE CIR N
Practice Address - Street 2:SUITE 118
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5630
Practice Address - Country:US
Practice Address - Phone:951-461-0615
Practice Address - Fax:951-296-1943
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-09
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP13077235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist